Laryngeal Manifestation of Autoimmune Disease: Rheumatoid Arthritis Mimicking a Cartilaginous Neoplasm

Abstract

A 56-year-old male presented with acute airway obstruction. He reported rapid progression of dyspnea over the last few days since developing an upper respiratory infection. The patient had been followed by an otolaryngologist for slowly progressive dyspnea over a 1?-year period following an upper respiratory tract infection. Recently, while under treatment for “atypical” asthma, he had undergone a flexible bronchoscopy. A subglottic lesion was noted and biopsied. He reported dysphagia of solids and a recent 10-pound weight loss. He quit tobacco use 25 years earlier and had been treated 5 years previously with nonsteroidal anti-inflammatory drugs (NSAIDs) for arthritis. On examination, the patient demonstrated biphasic stridor, with suprasternal retractions. Flexible fiberoptic laryngoscopy revealed bilateral vocal fold immobility, with edematous vocal cords fixed in the midline. The glottic aperature was estimated to be 3 to 4 mm. The respiratory rate was 16 to 18 breaths per minute, and oxygen saturations remained above 95% on room air. The patient was administered a helium-oxygen mixture by mask and intravenous dexamethasone (10 mg every 8 hours) and was placed in a monitored setting. Within 24 hours, his symptoms improved. Laboratory investigations, including a complete blood cell count, differential white blood cell count, electrolyte levels, liver function tests, thyroid function test, blood cultures, and urine analysis, were unremarkable. Antineutrophilic cytoplasmic antibody and syphilis (Venereal Disease Research Laboratories) serologies were also negative. The erythrocyte sedimentation rate was elevated to 80 mm/h (normal < 20 mm/h). A computed tomographic (CT) scan of the neck (Figure 1) exhibited a soft tissue lesion involving the posterior region of the subglottis and contiguous circumferential thickening of the cricopharyngeus. The lesion appeared to be distinct from the thyroid gland. Barium swallow revealed no mucosal abnormalities. The patient was brought to the operating room for tracheostomy, panendoscopy, and biopsy. On laryngoscopy, a white, friable soft tissue lesion situated in the left posterior subglottis was biopsied. An interarytenoid band was noted and lysed. Both cricoarytenoid joints were immobile to palpation. A firm circumferential submucosal thickening of the cricopharyngeus made passage of a 10 mm esophagoscope difficult. The remainder of the esophagoscopy and bronchoscopy was normal. Multiple biopsies were taken of the subglottis and proximal esophageal mucosa. Pathologic examination of the subglottic lesion was reported as squamous mucosa with focal acute and severe chronic nonspecific inflammation of the stroma with significant eosinophilia. There was no evidence of malignancy, vasculitis, necrosis, or granuloma. Special stains were negative for microorganisms. Esophageal